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The Community Health Worker, a member of the broader multi-disciplinary care team and will have the opportunity to make a profound impact on the lives of ACO patients experiencing homelessness or housing instability in addition to medical, behavioral and/or substance use disorder issues. The Community Health Worker will serve as a critical link for patients, the health center multi-disciplinary teams and community-based and hospital-based services.
Responsibilities:
Specific responsibilities include:
Serve as the liaison between the health center (primary care teams, case managers, integrated behavioral health, etc.) and external community-based organizations, hospitals, ER departments, and other facilities
Coordinate with Behavioral Health (BH) and Long-Term Services & Supports (LTSS) Community Partners (CPs) to ensure seamless handoffs, appropriate exchange of information, and to facilitate the review and approval of the patients comprehensive assessment and care plan
Coordinate with the Transitions of Care (TOC) team to ensure seamless handoffs, appropriate exchange of information and effective co-management of patients with a medical or behavioral health hospital admission or emergency department visit
Coordinate with homeless shelters, behavioral health institutions and others as needed
Participate in the integrated care team meetings and huddles
Work directly with patients in clinic on Health-related Social Needs and Care Coordination services
Assist patients in accessing community and government-based service agencies including possibly filling out paper work for patients
Conduct telephonic outreach to the yet-to-be-reached and lost-to-contact patients
Utilize a variety of outreach strategies to engage the health center ACO population
Educate and inform patients on services/programs offered
Arrange transportation for patients
Work closely with the clinical team to support patient engagement and confirm the patient has connected with resources, as appropriate
Contact provider offices and other clinical settings to obtain clinical data and/or patient demographics to facilitate care
Other duties as required
Qualifications (required):
Prior experience working in primary care, preferably community-based health center experience
Prior care coordination and/or administrative experience in the health care field
Good computer skills including proficiency with Microsoft (Office, Excel, Word)
Excellent relationship-building, communication and engagement skills
Ability to work independently and solve problems
Strong organizational skills and attention to detail
High level of professional and interpersonal skills
Ability to positively influence others with respect and compassion
Willing and interested in learning new skills
Flexible and comfortable with ambiguity and change
Bilingual skills in English and Spanish
Reliable transportation and ability to travel between locations
Preferred (not required):
Knowledge and experience with eClinicalWorks electronic health record
Experience working with patients with chronic and behavioral health needs
Demonstrated success in working as part of a multi-disciplinary team including communicating and working with providers, registered nurse, MAs, and behavioral health teams
Healthcare-related certificate degree, Massachusetts CHW certificate, or bachelors degree/ Medical assistant, home health aide, nursing assistant or other similar health care training
Experience working directly with patients, physicians, physician office staff, healthcare team, etc. telephonically (i.e. call center)
Experience with Medicaid / MassHealth
We offer a competitive salary, health, dental and vision insurance, disability coverage and unlimited vacation time.
